Transcript Anorectal human papillomavirus (HPV): An Often Missed

Anorectal human
papillomavirus (HPV):
An Often Missed Health
Assessment and
Treatment Concern
Jeffrey W. Huyett, MS, APRN, BC
Callen-Lorde Community Heatlh Center
356 West 18th Street
New York, NY 10011
[email protected]
212/271-7200
PURPOSE
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To inform about anorectal HPV
conditions, especially anal
intraepithelial neoplasia (AIN)
Describe an NP practice model for
screening and intervention not
commonly considered for both men
and women in primary care.
Assess disparities in preventative
screening for anorectal HPV
Human Papillomavirus
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OVER_100 DIFFERENT TYPES OF SMALL, DOUBLE
STRAND DNA VIRUS CAUSING EVERYTHING
FROM PLANTAR WARTS TO LARYNGEAL CANCER
Types 16 & 18
Types 31, 33, & 35
Types 6 & 11
- oncogenic (Cervical
&Anal Ca)
- intermediate risk
- low risk (condyloma)
Why be concerned with
anorectal HPV?
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Nearly 50% of Americans carry HPV (2,4,7,8)
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80-90% of anorectal carcinomas in men and women are
caused by HPV (2)
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In US, anal cancer in men who have sex with men (MSM) is
more common than cervical cancer in women (8)
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HIV-negative gay men experience anorectal carcinomas at the
same rate of cervical carcinoma 40 years ago, a rate
35:100,000 (4,8) That’s 4 times higher rate.
HIV+ gay men experience carcinomas at double that rate of
HIV- counterparts (1,2,4,7) That’s 9 times higher rate.
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HIV+ men/women experience anorectal intraepithelial
neoplasia (AIN) at similar rates (2)
57% of HIV- MSM HPV+; 27% with high-risk strains Five or
greater sexual partners nearly always confers HPV infection
(8)
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No uniform standards exist to screen the anorectal canal for
dysplasia or HPV except in New York State
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Guidelines for the screening the cervix of HIV+ women are
concise and clear (2)
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Condoms are not completely effective prevention of HPV
Assumptions:
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The anus is an equal opportunity sex organ
American culture, including medicine, is
uncomfortable with this portion of our
bodies
For MSM, anal problems can reinforce any
shame, stigma or guilt associated with “anal
sex.”
HPV is the most common sexually
transmitted but there is little common
knowledge
Orthonovum Pharmaceutics
Primary Care Screening
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Anal PAP: “Fluid
washing or brushing”
CPT: 88104
Fluid-based cytology
method using commercial
brands used at your
particular lab, eg.
ThinPrep®, PreservCyt®
(1,2,3,4)
Discuss this with cytologists
at your referral labs prior to
initiation.
Use either a dacron swab or
cytobrush
Part the anoderm, insert
about 1.5-3 inches
Rotate 360 degrees both
ways while extracting
Stir into fluid for at least 30
seconds
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HPV Testing: “noncervical HPV DNA”
CPT: 87621x2
Hybrid Capture DNA
Probes: Digene® (1,2,3,4)
Obtained with a cytobrush
into a specific transport
medium
Reports different strains of
HPV to determine
oncogenic risks
– High-risk: 16 & 18
– Low-risk: 6 & 11
– Intermediate risk Types
31, 33, & 35
– Allows for tandem
interpretation of
cytology
Anal Self-screening
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Many US clinicians are very
uncomfortable with self-testing
For uninsured or those with poor
access, self-screening can enhance
access
Avoid system or providers, initially
Anal Pap Interpretation (3)
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Cervical PAP using
Bethesda System
Negative
Atypical squamous cells
Low grade squamous lesion
(CIN I)
High grade squamous lesion
(CIN II and CIN III)
Invasive carcinoma
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Anal PAP
Negative
Atypical squamous cells
Low grade squamous lesion
(LSIL)
High grade squamous lesion
(HSIL II and HSIL III)
Invasive carcinoma
Anal Pap Smear Screen Process for Anal Cancer Prevention
Low-resolution anoscopy
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A must for any patient with a history of anal sex
Welch Allyn hand-held scope (36019) with
disposable speculum (53110)
Or, Leisegang clear plastic anoscope (82420) with
an external light source
Anoscopy CPT 46600
High Resolution
Anoscopy(HRA) (6)
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Comparable to colposcopy using a colposcope
Clear plastic anoscope
Acetowash with tetracaine 2% gel
Lugol’s dye application
Teislers biopsy forceps for sample retrieval
Colposcopy/HRA CPT 46615
Biopsy of Skin 11100/11101
condyloma
HSIL
Squamocolumnar junction
acetowhitened
Treatment of HSIL/AIN
(1,2,4,5)
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Infrared coagulation (IRC):
TCA: CPT 46900
Cryosurgery: CPT 46916
Electrocautery: CPT 46910
Surgical excision
Laser excision
HspE7?
Imiquomod?
CPT 45190
Infrared Coagulator (IRC)
(5)
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IRC is a safe office-based modality for
treating anal HSIL
While recurrence rates are high, they
are comparable to results seen in the
cervix and in another surgical series
Successive treatments led to
decreased recurrence rates, but
patients should continue to be
followed for disease
Hypothesis
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If AIN is the anal squamous cell
carcinoma precursor, then by ablating
HSIL we could prevent progression to
SCC.
We began using the IRC2100 “TM”
Infrared Coagulator (Redfield
Corporation, Rochelle Park, N.J.) to
ablate intra anal HSIL in 1999
IRC2100 “TM” Infrared
Coagulator
Light
guide
Redfield Corporation, Rochelle Park, N.J.
Implications of the
current state of HPV Care
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Prevention methodologies will be a new concept for many
patients, especially male
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Community standards do not exist and therefore community
sentiment is ambivalent
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Preventative management of any HPV condition reduces
treatment morbidity compared to extensive treatment of
advanced disease (1,2,4,5,8)
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PAP smears allow for risk assessment, diagnostic and
treatment decisions can follow (8)
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PAP smear may be first identification of HPV infection, first
detection of intrarectal condyloma. Can prevent surgery (8)
Research needs
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Generalizable protocols regarding
epidemiology, screening and detection
methods
Prevention vaccines
Primary care screening methods
Effective suppressive therapy
Self-treatment methods
Pharmacologic or immunologic therapy
for AIN
Policy Needs
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Standards of care
Health Education
Vaccine requirements
Provider training
Conclusions:
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Anal PAP screening should be done
within any HIV primary care setting
Routine anal PAP screening is a
primary care function
AIN detection and treatment exists
Advocacy will be essential
Need to develop treatment networks
Further research and development in
screening and treatment necessary